Principles of the effects of teratogens

Continue the treatment of the concept of interaction with a lecture about the principles governing the effects of teratogens. You will also find that this material provides opportunities to expand and clarify other developmental constructs as well.

A good source of these principles is the third edition of Hetherington and Parke's (1986) Child Psychology: A Contemporary View. Six principles listed and discussed there (pp. 108-111) include (a) the effects of a teratogen vary with the developmental stage of the embryo; (b) because individual teratogens influence specific developmental processes, they produce specific developmental deviations; (c) both maternal and fetal genotypes can affect the developing organism's response to teratogenic agents and may play an important role in the appearance of abnormalities in offspring; (d) the physiological or pathological status of the mother will influence the action of a teratogen; (e) the level of teratogenic agent which will produce malformations in the offspring may show no or mild detrimental effects on the mother; and (f) one teratogen may result in a variety of deviations, and several different teratogens may produce the same deviation.

Another way to organize your presentation on teratogens is according to the principle applicable to each teratogen's effects. Alternatively, you could assign that task to the students in the class, who would use teratogens that you describe or those discussed by Santrock in the textbook.

Dangers of Drug Use during Pregnancy

Information about the teratogenic effects of "everyday drug use" is very important to students as present or future parents. You may wish to underscore this with a lecture that explores this issue in greater depth than is possible in the text. Place special emphasis on the potential dangers of even normal everyday drug use, in particular the use of caffeine (coffee), nicotine (cigarettes), and alcohol.

Some important points to sketch include: (a) There are graded effects of these teratogens, such that increasingly it is risky to talk about "safe" levels of use. For example, taking just one drink a day increases risks for developmental disorders associated with alcohol use. Fetal alcohol syndrome is not an all-or-nothing outcome, but has more and less severe variants. (b) Effects may be direct or indirect. Alcohol use may lead to organic abnormalities; nicotine use may lead to temperamental difficulties in babies that influence the quality of their interactions with their caregivers. (c) Risks can be vitiated by discontinuing use of the drug. It is not reasonable to continue using a drug on the grounds that harm has already been done and cannot be reversed. (d) Risks may be variable at different times during prenatal development, a point related to the immediately preceding point. (e) The drug use habits of both parents can affect the fetus, either directly or indirectly. Indirect smoke could be a worry (we know, however, of no research on this point yet); the quality of care and support a husband can provide to his pregnant wife could influence the outcome of the pregnancy.

An important addition to your lecture could be a treatment of how mothers (and fathers) can deal with drug use habits that may endanger their unborn baby. Identify and cite specific programs in your area designed to help drug-using parents.

Images of Prenatal Development

A compelling way to bring home the value of observation as a research technique and, at the same time, prenatal development as a pivotal period in human development is to present and discuss images of prenatal development. A particularly interesting approach here would be an historical overview of the means by which scientists have been able to learn about the prenatal period. Consult older texts for pictures and discussions of life before birth. If neither you nor your students are too bothered by the idea, see if you can obtain specimens of human embryos or fetuses from your Biology Department, or a cooperating hospital. If you can compare these to specimens of other animals, you may enjoy a spontaneous discussion of the similarities and differences between the prenatal forms of humans versus other mammals.

Culminate your lecture with a series of in vivo photographs, movies, or a videotape such as The Everyday Miracle of Birth. Discuss how the ability to obtain such images has changed our conception of prenatal development and capacities, and influenced the quality of care available to pregnant women and their unborn babies. You may also find it important to talk about how the availability of such information has influenced views and arguments about abortion, or the psychological life of babies before birth.

Legal issues involving pregnancies

Each advancement in reproductive technology poses difficult moral and social issues, which will eventually be considered in state and federal laws, and in the courtroom. For example, one legal issue concerning artificial insemination with donor sperm (AID) is whether or not the offspring have a right to know the identity of the genetic father. Practicality suggests that AID children would benefit from access to genetic and medical information about their biological father's family, and that knowledge of the donor's identity would help prevent the possibility of marriage between two persons with the same donor.

On the other hand, offspring might wish to contract their genetic fathers, but end up intruding on another family's right to privacy. In one Australian study of 67 sperm donors, about 60 percent indicated that they would not mind being contacted by an adult child conceived with their donated sperm; however, those who wish to make contact may not neatly match up with those who feel comfortable being contacted. Could an AID child demand to be part of his genetic father's will, or could the donor demand to have visitation rights with his child?

Moreover, there are few regulations over the use of donor sperm. Perhaps there should be limits on the number of inseminations done using the sperm from one donor. What would be an appropriate number-five offspring? 20 offspring? As number of offspring from one donor increases in a small geographical area, the chance increases that these AID children will meet each other. There have been cases in which medical doctors have broken confidentiality and intervened when they have known that AID children with the same genetic father had become intimate or planned to get married. What other controls should be placed on the donor? Should there be mandated psychological screening of donors? Should wives of married donors provide informed consent for the procedure?

In another court case, a woman is suing a sperm bank for artificially inseminating her with the wrong sperm. In 1985, a couple stored the husband's sperm because he would become infertile from chemotherapy for cancer. The following year, the husband's health grew worse and the wife decided to have the baby as soon as possible believing that "having his child was the bond that would link us together.'' However, DNA tests on the child and on the husband's remaining deposits at the sperm bank confirm no genetic link between the two. How responsible would you hold the sperm bank personnel for this error?

While many ethical decisions have not been legislated and are left to the medical profession and couples involved, both the United Kingdom and Australia passed laws in the 1980s that stated that when both husband and wife have given consent to the AID procedure, the child is considered a child of the marriage.

The United Kingdom and Australia have also passed legislation on IVF and surrogate pregnancy procedures. The Australia Infertility Act of 1984 permits IVF to be performed only in approved hospitals on behalf of married couples who have had unsuccessful prior infertility treatments and have had counseling. In contrast, one problem in the United States is the profusion of infertility centers that often provide misleading statistics about their success rate with IVF and other procedures.

Similar to Australian law, the United Kingdom's Surrogacy Arrangements Bill of 1985 prohibits the recruitment of women as surrogate mothers, and prohibits the advertising of surrogacy arrangements. In the United States, where more than 500 babies have been born to surrogate mothers, ground rules for surrogate pregnancies are being hammered out slowly and painfully in the courtrooms. One celebrated case involved the rights of surrogate mother Mary Beth Whitehead over "Baby M,'' the baby she bore for the Sterns couple.

One actual court case in 1989 involved what to do with seven frozen fertilized eggs of a divorcing couple in which the woman wanted custody for future implantation and the man wanted say on the future of the embryos, because he did not want to father children in a single-parent situation (Sanders, 1989). How would you decide this case? At the Circuit Court level, a judge gave custody to the mother because "human life begins at conception'' and "it is to the manifest best interests of the child or children in vitro that they be available for implantation.'' Critics believe that the judge should not have made a statement about when life begins, but should have weighed the respective interests of each spouse. What do you think?

In addition to legal issues involving the new ways to conceive babies, growing concern exists about human embryo research. As of 1987, 25 states had laws barring nontherapeutic fetal research. Some scientists believe that embryo research is needed both to improve IVF and embryo transfer knowledge and to improve knowledge in the areas of cancer cell research and drug testing. Two proponents of embryo research have said, "The minimal characteristic needed to give the embryo a claim to consideration is sentence, or the capacity to feel pain and pleasure. Until the embryo reaches that point, nothing we can do to the embryo can harm it.'' (Singer & Kuhse, 1987; p. 136).

A strong opposing position to embryo research is presented by George Annas (1987) who said, "Unrestricted embryo experimentation could also lead to a less rosy future. A future in which 'motherhood'' is abolished and made-to-government-specification children are the norm. A future in which prefabricated human embryos are frozen and sold in supermarkets and through mail order catalogues. A future in which a woman could order twins or triplets, and a future in which a daughter could give birth to her genetic sister, who could, in turn, give birth to her genetic mother."

"We can also picture a world in which human embryos are fabricated not for reproduction but purely for experimental purposes. The embryos could be used for such things as testing the toxicity of new drugs, chemicals, and cosmetics, much the way in which rabbits' eyes are now used. Are these developments we should look forward to and encourage? Fairy tales we can afford to ignore? Or real dangers we should attempt to avoid by reasonable legislation and regulation?'' (p. 138)

What do you think? What should and can be done? Compare your views with those of others in your class.

(Sources: Andrews, 1984 (December) Yours, mine and theirs. Psychology Today, 20-29; Annas, 1987. The ethics of embryo research: Not as easy as it sounds. Law, Medicine & Health Care, 14, 138-140; Hartmann, 1987. Reproductive rights and wrongs. New York: Harper & Row; Kantrowitz, B., Kaplan, D. A., Hager, M. & Wilson, L. 1990 (March 19). Not the right father. Newsweek, 50-51. Kirby, 1987. Medical technology and new frontiers of family law. Law, Medicine & Health Care, 14, 113-119.; Singer & Kuhse, 1987. The ethics of embryo research. Law, Medicine & Health Care, 14, 133-137; Waller, 1987. New law or laboratory life. Law, Medicine & Health Care, 14, 120-140.; Woodward, 1987. Rules for making love and babies. Newsweek, March 23, 42-43; Sanders, A. L. 1989 (October 2). Whose lives are these? Time, 19.)

Ectopic pregnancies

Ectopic pregnancy is pregnancy in any location other than in the uterus (e.g., Fallopian tubes, ovaries, cervix, peritoneal cavity). Ninety-five percent of ectopic pregnancies occur in one in the fallopian tubes. From 1970 to 1980, the rate of ectopic pregnancies in the United States increased from 4.5 to 10.5 of 1,000 reported pregnancies. About 40,000 ectopic pregnancies occur each year. Ectopic pregnancies cause 5.7 percent of all maternal deaths.

Several conditions of the fallopian tubes can retard or prevent passage of the fertilized ovum and result in ectopic pregnancy; (1) Salpingitis is caused by sexually transmitted diseases or by a postpartum or postabortion infection. In this condition, the cilia of the fallopian tubes are reduced and the tube itself is constricted, resulting in a slower movement of the fertilized ovum through the fallopian tube. (2) Infections following abortion, puerperal sepsis, salpingitis, or appendicitis, or infections due to intrauterine devices or endometriosis complications can result in peritubal adhesions. (3) Postoperative scarring can delay the progress of the fertilized ovum in the fallopian tube. (4) Transmigration occurs either when an "ovum is fertilized before it is in the fallopian tube, or when a fertilized ovum enters the uterus and then continues to move into the opposite fallopian tube.'' (5) Some ectopic pregnancies occur after tubal sterilization, especially when the tubal cauterization technique was used. Sometimes recanalization allows passage of the sperm, but the fertilized egg cannot pass through. (6) About 10-20 percent of all pregnancies that occur with an intrauterine device (IUD) in place are ectopic.

Although most ectopic implantations are in the fallopian tubes, 5 percent are implanted elsewhere. The second more common site of ectopic pregnancy is abdominal pregnancy. If the embryo is properly nourished, it continues to develop, occasionally to term. More often, the infant dies before the fortieth week. Cervical pregnancy occurs in one of every 15,000 pregnancies. This location results in profuse bleeding in the early months of pregnancy. Maternal mortality is high with this type of pregnancy, and hysterectomies sometimes must be performed to control hemorrhage. Ovarian pregnancy is also rare and almost always requires partial or complete removal of the involved ovary. Ectopic pregnancies in the fallopian tubes may go on from 4 to 16 weeks before causing rupture, depending on the specific location of the implantation. Severity of symptoms and risk for profuse bleeding and death also vary with the location without the fallopian tube.

No specific type of pain is characteristic of ectopic pregnancy, but over 90 percent of patients report abdominal pain. Twenty-five percent of cases have the classic triad of abdominal pain, vaginal spotting, and amenorrhea. Before tubal rupture, the majority of patients have adnexal tenderness. Ectopic pregnancy needs to be differentially diagnosed from corpus luteum cyst, follicular cyst, twisted ovarian cyst, salpingitis, and appendicitis. The doctor can use the HCG testing, pelvic ultrasonography, and laparoscopy to improve diagnostic abilities and detect ectopic pregnancies before rupture. The treatment of choice is conservative surgery, preferably by basic laparoscopy for all unruptured tubal ectopics. (Source: Fayez, J. A. 1990 (January). Ectopic pregnancy: Early detection and treatment. Hospital Physician, 21-30.)

A History of Abortion

Check your knowledge about the history of abortion by taking this short true-and-false quiz (next page):

1. The first time abortions were legal in all states was after the Supreme Court made its decision in Roe vs. Wade in 1973.

2. Abortion techniques were first developed in the nineteenth century.

3. As today, nineteenth-century feminists were strong advocates of a pro-choice position and resisted attempts to make safe, early abortions illegal.

4. Currently, China has one of the lowest rates of abortion.

5. From the time of the early Church, Christians have opposed the use of abortions.

6. Adolf Hitler encouraged the widespread use of abortions.

The scoring of this quiz is fairly simple, for all six statements are false. Most individuals consider only the last three decades when thinking about abortion, but the history of abortion goes back many centuries. Chinese medical texts printed in 2737 B.C. included abortion techniques, and ancient Greeks, Romans, and Hebrews all permitted some abortions in their cultures. From the beginning, there have been several cycles of permitting abortions and then severely restricting abortions, and the proponents and opponents of legalized abortions often change.

Early Christians believed that abortions were not murder as long as they were performed before the soul entered the body. It was not until 1869 that the Roman Catholic Church took a strong anti-abortion position, when Pope Pius IX declared that followers would be excommunicated for any abortion, even those performed to save the life of the pregnant woman. Some church officials hold this opinion in the 1990s, too. New York Cardinal John J. O'Connor proposed excommunication for politicians who supported legal abortions or helped to make public funds available for abortion.

Few legal restraints existed in England from 1307-1803, and from 1607-1828 in America. In general, common law allowed abortions if performed before quickening. After quickening, abortion was considered a misdemeanor. English law changed in 1803 when King George III decided that abortions before quickening were punishable by a fine, whipping, imprisonment, or oversea deportation up to 4 years. Abortion after quickening was considered murder, punishable by death. By 1861, all women who had abortions could receive life imprisonment.

In 1821, Connecticut became the first state to pass a law that forbade abortions after quickening. New York state passed a stricter law in 1829 and allowed abortions only to preserve the mother's life. Other states began to pass more restrictive laws, too. After the Civil War, the anti-abortion drive was most strongly supported by upper-class, white, Anglo-Saxon Protestants who wanted to raise the birthrates among Americans to counterbalance the high birthrates among immigrants. Other anti-abortion supporters during this era were anti-obscenity crusaders and feminists. Early feminists perceived abortions as a byproduct by women's suppression and suggested abstinence as an alternative. In 1871, the New York Times called abortion "the evil of the age.'' The combined efforts of these groups worked; by 1900, all abortions were illegal except those in which the pregnant woman's life was endangered.

Through the 1980s, the two countries with the strictest restrictions against abortion were Iran and Romania. Romania even had "birth squads'' that visited childless couples and encouraged them to become parents. Married Romanian women were subjected to mandatory monthly medical exams; if the exam determined that a woman was pregnant, she could be imprisoned if she did not deliver a baby in nine months. This practice in Romania led to an outbreak of infants with AIDS that was detected shortly after the downfall of dictator Nicolae Ceausescu. Because birth control and sex education were outlawed in order to boost the population, many infants were sick or orphaned and received blood transfusions with dirty needles. In these settings, about one third of all young children were infected.

Attitudes about abortion and beliefs about whether abortions should be legalized are often forced into the either-or positions of pro-choice or anti-abortion, but the issue is much more complex. Some people believe that abortions should be allowed for any reason during the first trimester. Others believe abortions should only be used if the mother's health is threatened. The majority of people-over 80 percent-believe that abortions should be allowed when the fetus has a major genetic or developmental defect. However, prenatal diagnoses of these defects often cannot be made until the second trimester, which many people think is too late for an abortion. It is difficult to resolve the conflict between wanting to permit only first-trimester abortions and knowing that a 5-month-old fetus has a neural tube defect, Tay-Sachs disease, or Down Syndrome.

The above conflict represents the conflict between two reasons for having abortions: (1) to end an unwanted pregnancy, and (2) to end the pregnancy of a defective fetus. The first reason can be decided early in pregnancy; the second reason usually cannot. While a high percentage of the population believes that defective fetuses may be aborted, the timing of these abortions occurs when potential parents have already grown attached to the developing fetus and are full of delightful expectations about the baby.

Abortions can also be used to enforce government policy, as evidenced by the one-child policy in China. The current population of China is over one billion individuals, and government officials wish to reduce the population to 700 million within 100 years. The Chinese are encouraged to get married later, to pledge to have only one child (cash subsidies are given for pledging), to get sterilized, and to abort later pregnancies. In fact, some women may be forced to have abortions. From 1900 to 1987, the global population grew from just over 1 billion to 5 billion. Some experts expect the population to grow to over 10 billion by 2110. Perhaps along the way other countries will decide to encourage or even enforce abortions for women.

Another concern is who makes the decision to have an abortion. Some feminists believe that the decision to have an abortion should be made solely by the pregnant woman. Others want the husband or boyfriend to be involved in the decision, and to be able to prevent a woman from having an abortion. Health professionals, lawmakers, judges, and parents may be part of the decision-making process in some cases. Should a pregnant teenager need her parents' consent if she wishes to have an abortion? The permission of her 15-year-old boyfriend? His parents? The courts?

During a five-year period in which Minnesota had a parental consent law, 99.9 percent of minors who used the judicial bypass system were ruled mature enough to make the decision alone. Meanwhile, the court system became crowded with these cases, and the teen birthrate increased 38 percent in Minneapolis alone. Some abortions took place in the second trimester instead of the first because of delays in the judicial bypass system. The Supreme Court has given states permission to have laws that required a pregnant teenager to inform a parent before an abortion.

What conditions would you put on the right to an abortion? For what reasons should a woman be able to get an abortion? Which individuals should be part of the decision-making process. Are there any conditions or circumstances under which women should be forced to have an abortion?

How do attitudes toward abortion shift as technology provides new means for abortion procedures? Mifepristone or RU 486, an orally administered medication, can effectively (96 percent of the time) terminate pregnancies within 49 days of amenorrhea (Silvestre, et al., 1990). (Sources: Planned Parenthood of Mid-Iowa, Fall 1989; Purvis, A. 1990 (February 19). Romania's other tragedy. Time, 74; Woodward, K. L. & Talbot, M. 1990 (June 25). An archbishop rattles a saber. Newsweek, 64; Silvestre, L. et al. 1990 (March 8). Voluntary interruption of pregnancy with mifepristone (RU 486) and a prostaglandin analogue: A large-scale French experience. New England Journal of Medicine, 322, 645-648.)

Examples of Cross-Cultural Birth Practices and Beliefs

West Africa: Women are expected to give birth without making any sounds; girls who cry out are called cowards and are expected to have longer labors.

Latin American peasants: Massaging to direct the baby down, and using long pieces of cloth bound across the upper abdomen in the belief that babies might otherwise travel upwards instead of descending into the vagina.

East Africa: Women in long labors have their vaginas packed with cow dung to encourage the baby to want to be born (i.e., the baby will believe it is being born into a wealthy family).

Cuna Indians of Panama: The shaman sings the baby out of the woman's body

Zuņi Indians: Birth takes place on a hot sand bed 20" across and 5" high covered by a sheepskin. The sand bed is symbolic of Mother Earth.

The Zia of New Mexico: The father dips eagle feathers in ashes and throws the ashes in the four directions. Then he draws the ashy feather down the pregnant woman's sides and center of the body while praying. The father's sister places an ear of corn near the pregnant woman's head and blows on it during the next contraction to aid the father's prayer.

India: A budded flower is placed near the pregnant woman and her cervix is encouraged to dilate as the flower's petals open.

Manus of New Guinea: The husband and wife are to confess any hidden angers toward each other so that the childbirth process can proceed normally. A hot coconut soup is used to comfort the mother. Jamaica: Childbirth is quickened if the mother smells the sweaty shirt of the father.

(Source: Examples come from Ch. 5 of Kitzinger, S., 1980. Women as mothers: How they see themselves in different cultures, NY: Vintage Books.)

Medical Advances: Pregnancy in Diabetic Women

Although diabetes still poses serious, even fatal problems for pregnant women and developing fetuses, the statistics have changed dramatically in the twentieth century. Maternal morality among diabetics fell dramatically after the discovery of insulin in 1922. However, for decades, stillbirths and neonatal deaths from pregnancies complicated by diabetes continued to be higher than 1 in 3. Now, the mortality has dropped to only three percent. Two major reasons for this decrease: (1) technology that tells if the fetus' existence is endangered; through quick delivery, and using neonatal intensive care units, many survive; (2) self-monitoring of glucose levels is now practical.

However, the number of congenital anomalies in the offspring of diabetic women has remained three times higher than those of offspring of nondiabetic women. It seems that maternal hyperglycemia during the first eight weeks of gestation when organs are forming is the major cause.

A Diabetes in Early Pregnancy Study found that when diabetic women begin monitoring glucose levels prior to a planned pregnancy, the rate of spontaneous abortions and birth defects was not much higher than for other pregnancies. With prior monitoring, 4.9 percent of offspring had major malformations; for those who began monitoring after the twenty-first day after conception, the birth defect rate was 9 percent.

Pregnant diabetic women with markedly elevated glucose readings had a 45 percent spontaneous abortion rate; when initial levels were near normal the rate was 15 percent. In other words, the time to prevent birth defects and spontaneous abortions for diabetic women is before conception. (Source: Coustan, D. R. 1988 (December 22). Pregnancy in diabetic women. The New England Journal of Medicine, 319, 1663-1665.)

CMV Transmission

CMV stands for cytomegalovirus, a virus that can be dangerous to the unborn children of pregnant women. Experts are especially concerned about CMV being passed from infants and young children to pregnant care providers since CMV can be passed in the children's saliva and urine. Risk occurs, for example, when day care workers change diapers, have contact with mouth toys, kiss near the mouth or on the hands, or share food, drinking glasses, or utensils with children. Frequent hand washing, immediate disposal of diapers, and wiping changing area and counter tops with soap and bleach and water can help stop the spread of CMV.

In a study by Jody Murphy of the University of Iowa, 100 day-care providers and 112 children were tested for CMV. At the commencement of the study, six percent of the children in family home day care and fifteen percent of those in large day-care centers were excreting CMV in urine. Among family home day-care providers, forty-three percent did not have evidence of CMV infection at this time. The study is an ongoing long-term CMV study, but during the early phase of the study, five percent of the uninfected providers had become infected with CMV. (Source: Cushman, D. (May 18, 1993). Day-care providers and parents must consider CMV transmission. Des Moines Register.)